Morning Report: 3/11/14

Here’s Dr. Grock with today’s Morning Report!

The Case:

65 yo F known CHF presents with palpitations. Compliant with home meds, except Coumadin. No chest pain/sob/change in ET/orthopnea/pnd/other complaints. EKG shows: afib, rate of 87. CBC/CMP/TSH/Ua/CXR unremarkable.

Plan?

Atrial Fibrillation/Flutter

Facts: irregularly irregular rhythm. Doubles mortality, increases rate of cva, vte, CHF, hospitalization. Decreases quality of life and exercise capacity.

Treatment plan: cardioversion

Symptoms < 48 hours – cardiovert on LMWH

Symptoms>48 hours – transesophageal Doppler and cardiovert (vs rate control)

Treatment Plan: Anti-coagulation

CHADS 2	Risk of cva/year	Risk of cva/day
	Score 0 1.9%	0.005%
CHF	Score 1 2.8%	0.008%
HTN	Score 2 4%	0.01%
Age>75	Score 3 5.9%	0.016%
DM	Score 4 8.5%	0.023%
CVA (2)	Score 5/6 12.5%	0.034%

CHADS2 = 0 – ASA vs nothing

CHADS2 = 1 – see CHADS-VASC,

if CHADS-VASC = 1 – ASA (can give Coumadin/dabigatran/rivaroxaban)

if CHADS-VASC = 2 or more – Coumadin/dabigatran/rivaroxaban

CHADS2 = 2-6 – Coumadin/dabigatran (noninferior, same cva reduction with lower bleeding rates)/rivaroxaban (noninferior in nonvalvular afib per 1 good NEJM paper). ARR 2.7% (NNT 37) for CVA, also decreased mortality.

CHADS –VASC:

1. Age 65-74 (1) ), >75 (2) 2. Male (0), Female (1) 3. CHF (1) 4. DM (1) 5. VTE (2) 6. Hx Vascular Disease (1)

Score CHADS2-VASC (%/y)

CHADS2VASC	0	1	2	3	4	5	6	7	8	9
%risk CVA/yr	0	1.3	2.2	3.2	4.0	6.7	9.8	9.6	6.7	15.2

As you can see the daily risk of stroke is incredibly low. New onset Afib on its own is not an admitting diagnosis, nor is sub-therapeutic INR.

Treatment Plan: rate vs rhythm control – Rate control primarily. Dilt best, can use metoprolol as well.Rhythm control if symptomatic with adequate rate control, young/asymptomatic patients who are not candidates for ablation, if AF secondary to correctable factor (eg hyperthyroid).

References

Camm et al. Guidelines for the management of atrial fibrillation. European Heart Journal 2010, 31.2369-2429 http://eurheartj.oxfordjournals.org/content/31/19/2369.full.pdf+html

Mason et al. Impact of the CH2DS2-VASc Score on Anticoagulation Recommendations for Atrial Fibrillation. The Amer Journ of Med. Vol 125, No 6, June 2012